Wednesday, May 14, 2014

Although the development of the clinical informatics subspecialty is an important accomplishment for the informatics field, I have a number of continued concerns about the optimal development of the subspecialty, especially now that the Accreditation Council for Graduate Medical Education (ACGME) program requirements for clinical informatics fellowships have been released. There are a number of aspects of training to be an informatician that just do not fit into the traditional model of clinical training, requiring those of us applying for program accreditation to fit proverbial square pegs into round holes.

Some of these concerns are also noted by Don Detmer and Ted Shortliffe in a new Viewpoint published in JAMA [1]. They raise concerns about:

The accreditation process that may fragment as a result of it being administered by nine different primary specialties

Program funding that will compete within healthcare institutions for other fellowship programs

National capacity for training subspecialists once the "grandfathering" period ends in 2018 and the only path to board certification is a full-time two-year fellowship

I have shared these and related concerns last year and the year before, and have also raised others. In the following sections, I will describe my major concerns, grouped under headings of the challenges with the rotations model, a more detailed description of the funding issues, and timing and flexibility issues.

Rotations

Many of these are related to traditional model for clinical training versus the graduate educational model that the field has historically employed. For example, clinical training historically is based on the notion of "rotations," which are blocks of weeks that trainees spend in a given setting. This makes sense in clinical training, where one learns by being exposed to a steady stream of new and returning patients, whether on a hospital ward or in a clinic. An internal medicine trainee, for example, can learn quite a bit about intensive care medicine by taking care of the steady number of patients who are admitted, treated, and then discharged from the intensive care unit over weeks or months of time. This is the traditional "steeped tea" model of clinical training, where the assumption is that steeping the learner among patients in a given specialty will result in learning, a model that has been challenged in recent years [2]. (And for which informatics tools may help, in better tracking the cases seen.)

The rotations approach makes even less sense in clinical informatics. Trainees, for example, will derive value from spending time in the clinical informatics department, the IT organization, the compliance (privacy and security) departments, and so forth. As we hope to create a multi-instutional fellowship program, fellows in our program will also gain exposure to informatics in other settings (e.g., managed care organizations, the Veteran's Administration Hospital, safety net clinics, and even industry settings). It is not clear, at least to me, that prescribing fixed numbers of weeks in specific settings makes any sense.

A related issue with rotations is that most informatics/IT projects evolve over months, if not years. Just as primary care physician trainees need continuity experiences, so do informatics trainees. Because of the long-term nature of informatics projects, these trainees should be, in by opinion, spending significant amounts of time in them. But with all the rotations, clinical work, courses, and so forth, there will be only intermittent hours in the week for any sort of longitudinal informatics project experience.

Funding

I applaud Detmer and Shortliffe for raising concerns about funding, although the brevity of their paper does not allow detailed exploration of the complex challenges. Many institutions fund clinical fellowship programs with the understanding that the cost will at least partially be offset by the clinical work of the fellows. Clinical informatics fellows will certainly be able to make tangible contributions to the organizations that sponsor fellowships. However, they will have competing demands for their time, such as clinical work, rotations, education, teaching, and so forth, that will reduce the value they can provide to their sponsoring institutions.

An additional issue is that some, perhaps many, positions in these training programs will be funded by specific medical specialties within healthcare organizations. Those funding the programs are likely to want to see some tangible contributions to their informatics/IT efforts, just as clinical trainees contribute to the clinical mission of organizations (i.e., internists see patients in the Internal Medicine Clinic). But again, with the myriad of clinical work, rotations, education, teaching, and other demands for their time, the amount that fellows will be able to contribute to informatics work in their specialties may be limited.

Also a funding issue is that most institutions are interpreting Centers for Medicare and Medicaid Services (CMS) rules to prohibit these board-certified or board-eligible physicians, practicing in their primary specialties, to bill for patient care. Thus one source of financial value that trainees could provide to their organizations cannot be financially realized. Some have suggested that fellows do their clinical work in other settings, i.e., moonlighting, but to me, not being part of the informatics team at the same place they are providing patient care is a real lost opportunity.

A final funding issue concerns ACGME requirements for faculty, staff, and program leadership time. In these times of ever-tightening budgets for academic medical centers, the requirement for 2.0 FTE of faculty time for programs that may only have a handful of fellows is not realistic. I know this issue has historically been "fudged" by clinical programs where faculty "supervise" trainees in clinical settings while simultaneously providing patient care, but this will be challenging for clinical informatics fellowship programs.

Timing and Flexibility

I have other concerns beyond funding that I have raised in the past about timing and flexibility. The two-year, full-time commitment will block the post-2018 pathway for many physicians who have established jobs, practices, and families. Our distance learning program has more than a decade of experience of allowing physicians (and others) to transition into informatics training and careers at their own pace. One of the other subspecialty fellowship program directors at OHSU doubted that many physicians in training would want to complete a clinical subspecialty (such as oncology) and then spend another two years pursuing informatics. He did believe that there would be great interest in a joint fellowship where a trainee could get "credit" for more than one subspecialty by, for example, embedding clinical informatics training in the 18-24 months that subspecialty physicians often get for more flexible portions ("research") of their fellowship.

Clearly there are some people who should train solely in informatics, at full-time and for extended periods. These should be the researchers and educators who will work in academia, industry, and leadership roles. But clearly many "practicing" informaticians will need to maintain strong ties to their clinical specialties as well as be efficient in their training to become a subspecialist. The ability to overlay or combine informatics training with training in other specialties is appealing to my colleague program director mentioned above (not to mention myself).

Conclusions

In the long run, these issues will need to be resolved, especially if the new subspecialty is to thrive. Our approach at OHSU is to move forward, get our fellowship established and accredited, and then hope that ACGME and others will have the flexibility to allow clinical informatics fellowships and the larger field thrive.